We need you! Join our contributor community and become a WikEM editor through our open and transparent promotion process.
Toxic epidermal necrolysis
From WikEM
Contents
Background
- Explosive dermatosis with tender erythema, bullae, and subsequent exfolliation
- Most commonly caused by medications
- Sulfa drugs, penicillins, anticonvulsants, and NSAIDs
- Other causes: infection, chemicals, malignancy, immunologic factors
Clinical Features
- Malaise, anorexia, myalgias, arthralgias, fever, painful skin, GI symptoms
- Extracutaneous manifestations may persist for 1-2 weeks following skin symptoms
- Exam with warm tender erythema with overlying flaccid bullae, erosions with exfoliation
- Positive Nikolskly's sign (able to rub off superficial layers of skin with pressure)
- Mucosal involvement (oral, conjunctival, respiratory, GU)
- Systemic toxicity
- 25-35% Mortality
- Death is usually caused by infection, hypovolemia, and electrolyte disorders
- Predictors of poor prognosis include: age, extent of disease, leukopenia, azotemia, and thrombocytopenia
Differential Diagnosis
- Toxic infectious erythemas
- Exfoliative drug eruptions
- Primary blistering disorders
- Stevens-Johnsons syndrome
Erythematous rash
- Positive Nikolsky’s sign
- Febrile
- Staphylococcal scalded skin syndrome (children)
- Toxic epidermal necrolysis (adults)
- Afebrile
- Toxic epidermal necrolysis
- Febrile
- Negative Nikolsky’s sign
Evaluation
- History of drug exposure
- Prodrome of malaise and fever
- Positive Nikolsky sign
- Oral, ocular, and/or genital mucositis with painful erosions
- Necrosis and sloughing of the epidermis
- Diagnosis is made my skin biopsy
- SJS vs TEN
- SJS - skin detachment of <10 percent of BSA
- TEN – skin detachment of >30 percent of BSA
Management
- Monitor cardiopulmonary status closely
- Correct fluid and electrolyte imbalances
- Attend to infectious complications
Disposition
- ICU
- Best cared for in a burn unit
- Immediate derm consult
References
<UpToDate>
